I was at my computer working when an emergency room nurse approached.
I had already seen her twice before. She was always crying out in agony. She would inject drugs into her legs leading to multiple deep infections. There was poor intravenous access, and once we established an IV, she accepted some medications and signed out against medical advice. I resented that she did not fill any prescriptions and did not see a primary care physician outside the ER.
I didn’t like taking care of her and viewed all of our efforts as futile. Her underlying issues of substance abuse disorder, unemployment and some other undiagnosed or untreated psychiatric disorder could not be adequately addressed in the ER setting. It seemed to me like she was purposely making herself sicker while frustrating me and our nurses further. I sent the resident to see her.
I am not alone in thinking that way. A study in the Archives of Internal Medicine found that the internal medicine physicians in practice found 15 percent or more of their patients to be “difficult.”
For busy clinicians seeing 25 or more patients per shift, that is three to four times per day that they are left feeling frustrated, resentful, defeated or inadequate.
Health-care professionals don’t like acknowledging these feelings. It can be unprofessional and contrary to the oaths we take when we graduate. That may be a reason this issue has not been well-studied or documented.
Intuitively, it would seem that mutual bad feelings between patients and their health-care team do not serve either party well.
In his groundbreaking article, “Taking Care of the Hateful Patient,” psychiatrist James E. Groves discussed the negative feelings and dread that physicians have toward some of their patients and how it affects both. “When the patient creates in the doctor feelings that are disowned or denied, errors in diagnosis and treatment are more likely to occur,” he wrote.
He noted that physicians taking care of these “hateful” patients were more likely to feel helpless, to unconsciously punish the patient, to punish themselves, to inappropriately confront the patient, or to avoid or remove them from the clinical setting. In other words, the doctors get more cynical and the patients get inferior care.
A study in the British Journal of Medicine documented that patients who believed that their doctors have compassion for them take their medications more consistently, follow through with treatments, experience better outcomes, rate their physicians higher and file fewer malpractice lawsuits, even when a mistake was made. It can be concluded then that the absence of compassion and perceived negative perceptions could lead to less compliance, less follow-through, poorer outcome and more patient complaints and lawsuits.
Critical care physician Rana Awdish, who serves as medical director of Care Experience for the Henry Ford Health System in Detroit, wrote about the problem of branding patients as difficult in her memoir, “In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope.” As she faced critical illness herself, she was identified as “difficult” by her nurse.
Awdish writes: “We label patients. We label them as cooperative, or drug-seeking, realistic, or difficult. It functioned as an abridged report to our colleagues of what to expect. ‘Difficult’ was shorthand for ‘The patient is not going along with the plan. I have a good solid plan, and they weren’t on board.’ … We insisted on creating a dynamic in which one person wins and the other loses.”
Health-care professionals judge patients one way or another because that is what humans do. Humans have a strong negativity bias and look for things that look wrong or dangerous. This tendency served our ancestors who had to be alert for danger well. We are experts at identifying what is wrong.
In addition, during training, I have heard teachers and colleagues use derogatory and demeaning language about patients who seem noncompliant, self-destructive and disagreeable. Thinking about some types of patients in negative ways becomes a terrible, habitual group way of thinking. Everyone in the medical workplace knows the “frequent fliers” — certain patients who return to the emergency department over and over again as their primary source of health care — and the “drug seekers” who show up every week.
There are several problems with all the harsh judgments that clinicians make so rapidly about patients.
We generally do not have all the information we need to formulate an accurate assessment. Because of confirmation bias, we tend to interpret new information as being supportive of the opinions we already hold. We search for things in the world that support the negative beliefs we already have. We also ignore evidence that disagrees with or does not confirm our preconceived beliefs.
In other words, we miss the actual diagnosis.
How to help
What can be done to address the issue from both sides?
For health-care workers, it is important to become more aware of the ways that we think and talk. We carry negative thoughts about some of our patients and that is a human and normal thing. Don’t beat yourself up about it. With awareness, you can redirect your thoughts. You can start by asking these questions:
- Can you imagine that the problems of your patients are your own? In that way, you can have compassion for their fear and anxiety about some symptom or a diagnosis that they do not yet understand.
- What else is true about this challenging person? Are they someone’s son or daughter? Do they have an undiagnosed or untreated psychiatric diagnosis?
- Could you be wrong about your plan? Are there other ways in which you could collaborate with the patient or the family of the pediatric patient to achieve your mutual goals?
- Can you give your patient or his family the benefit of the doubt? Can you consider what they might be thinking to make them feel and act in a “difficult” way?
Patients can also make their interactions with their health-care team less adversarial. They could understand that physicians are highly scrutinized as to the medications and treatments they prescribe, and each of us takes an oath to do our patients no harm. Patients can do these things:
- Bring a list of medical history, prior surgeries, medications and allergies. Reviewing these items are important safety issues.
- Prepare to report your symptoms (not suspected diagnoses) over and over again. Hearing a patient tell their own story is an important part of the physician’s evaluation.
- Allow yourself to be examined. A thorough physical exam is an important part of the diagnostic evaluation. Bring a support person or interpreter or ask for one to help with this.
- Avoid confrontation and threatening behavior. Health-care professionals tend to be organized and highly driven people who don’t like being manipulated, threatened or ordered around. Requests for medications and treatments are reasonable and patients can request explanations and expectations as needed.
- Explain to the physician and nurses any limitation in adhering to the plan: for example, lack of insurance, transportation or support system. The nurses and social workers can help provide more resources, but the staff cannot help unless they know the issues.
Joan Naidorf is a board-certified emergency physician, author and speaker based in Alexandria, Va. Her book, “Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals,” was published in January by the American Association for Physician Leadership.